Sports Cardiology & Preliminary Results From the Masters Athlete - - PowerPoint PPT Presentation

Sports Cardiology & Preliminary Results From the Masters Athlete Screening Study

Hollyburn Country Club, Presenter Series October 19th, 2016

• Dr. Saul Isserow - MBBCh, FRCPC, FACC

Medical Director, Sports CardiologyBC Barb Morrison - PhD student, MSc, BHK, CEP Research and Project Coordinator, Sports CardiologyBC

Outline

• Dr. Saul Isserow
• What is Sports Cardiology
• Background - Why Study Masters Athletes?
• Barb Morrison
• Preliminary Results of the Masters Screening Study

What is Sports Cardiology?

• “Aims to elucidate the cardiovascular effects of regular

exercise and delineate its benefits and risks, so that safe guidance can be provided to all individuals engaging in sports and/or physical activity in order to attain the maximum potential benefit at the lowest possible risk”

Heidbuchel, Eur J Prev Cardiology, 2013

www.SportsCardiologyBC.org

Evoluti

• n of

Physica l Activity

Evoluti

• n of

Physica l Activity

Good Reasons to Exercise Regularly

• Reduction in MI and sudden death
• Physical & mental well-being
• Positive feedback from successes
• Earning a living
• Peer group
• Weight loss

Phidippides (530 BC - 490 BC)

Athenian herald: Professional-running courier Ran 40km from Marathon to Athens to announce Greek victory over Persia ‘Nikomen’ – We have won Collapses and dies Luc-Olivier Merson, 1869

Why Study Masters Athletes?

• Middle-aged individuals are exercising more and living

longer

• Paradoxically, exercise can act as a trigger for a sudden

cardiac arrest in those with underlying disease

• Suggestions that there are potential harmful effects of

chronic endurance exercise (i.e. AFIB, CAD)

• Cardiovascular screening can prevent SCD, yet the
• ptimal method in this population has yet to be

determined

The Globe and Mail Published Thursday, Apr. 02 2015, 7:04 AM EDT

Canaccord Genuity CEO Paul Reynolds dies after incident during Hawaii triathlon

• 54% were older than 65 years of age...

Chugh S, Weiss B JACC, 2015.

Increasing Number of Masters Athletes

Exercise Paradox

Does Exercise Increase the Risk of SCD?

§ Small absolute increase in relative risk of SCD during

exercise

§ In the long-run,

physical activity is protective

Physiologic changes of exercise and potential sequelae

Thompson, Circulation. 2007 May 1;115(17):2358-68.

Marijon et al. Circulation. 2011

• 1. Underlying cardiovascular disease
• 2. Sport
• 3. Gender
• Greater predominance in males vs.

females (up to 30 fold more frequent) Primary cause of SCD in > 35 years is Coronary Artery Disease

• Number participating in

sport

• Intensity of sport

(physiological requirements)

Causes of Sports-Related SCD

Greater incidence of sports-related SCD in non-competitive and older athletes

94% of sports- related deaths in

• verall population

(majority of SDs were > 35 years)1 6 % of sports related deaths in the young athlete

Eloi Marijon et al. Circulation. 2011

Arem et al., JAMA Intern Med. 2015 Merghani et al, Trends in Cardiovascular Medicine. 2016.

Optimal Amount of Exercise?

é Troponin post exercise

• AF (5 fold é)
• ? Myocardial

fibrosis

• ? é RV

dysfunction

• ?é CAD

ê Obesity ê BP ê Diabetes ê Risk of CAD ê Risk of AF é Coronary reserve in CAD

Running 1-3 times/week provided same level of risk reduction as higher frequency or intensity of running

Detection of Coronary Artery Disease: Can you name 10 Risk Factors?

Non-Modifiable

• Age (↑)
• Gender (Male)
• Ethnicity (First Nations,

South East Asian)

• Genetics
• Family History
• 1st degree male <55 years or

1st degree female <65 years Modifiable

• Hypertension
• Diabetes
• Dyslipidaemia
• Smoking
• Physical Inactivity
• Obesity and Abdominal

Girth

• Psychosocial
• Alcohol Consumption

3 Categories: Low risk

(<10%) Moderate risk 10-19% risk High risk >20% risk FHx: multiply Framingham risk by 2

Framingham Risk Score (FRS): Calculating risk

For individuals 30-59 , double their score if cardiovascular disease is present in a 1st degree male <55 years or 1st degree female <65 years

What is the 10-year risk of a 60 year old man with normal lipids, non-smoker, normal blood pressure?

• A – 5%
• B – 10%
• C – 15%
• D – 20%

What if that same patient is now 70

FRS = 18.4%

• 50 male marathon runners (mean age: 52.7, range 45 -67 years)
• Marathons completed: 1-72, median 7, mean 13.8

Results Summary

• 50% of male marathon runners had mild-

moderate CAD despite favorable risk profile

• One had significant CAD
• Reported atypical chest pain
• Exercise stress test failed to detect those with

CAD

• Traditional risk factors did not differ between those

with and without CAD

Tsifilikas et al. 2015. RoFo

Potential Explanations

• Jim Fixx dilemma
• Excessive exercise versus previous bad habits
• Metabolic and mechanical stresses
• Potentially lead to accelerated atherosclerosis from oxidative stress
• Increased sustained levels of catecholamines
• Belief that exercise trumps a bad diet and smoking

Atrial Fibrillation

AF Prevalence

• Prevalence increases with age:
• persistent or paroxysmal AF
• ~0.5% in subjects aged 45-54 years
• ~1% at 55-64 years
• ~4% at 65-74 years
• diagnosed in 1% of the population by age 60
• >10% when older than 80 year
• Most common treated arrhythmia seen in ATHLETES

Prevalence of AF in athletes

• Dependent on:
• Age
• Sport
• Length of prior training
• Intensity of prior training
• Sex

AF Risk Factors

Wyse, JACC 2014

AF Risk Factors

AF Risk Factors

U-shaped curve?

>5x jog/wk è 53%é risk of AF

Exercise and AF

• Regular moderate

exercise has TREMENDOUS health benefits

• High-performance

endurance athletes and Olympic athletes live longer than the general population

DESIGN RATIONALE

Detection of:

1.

Coronary Artery Disease

2.

Atrial Fibrillation

3.

Valve Disease

4.

Inherited Heart Disease

Cardiovascular Imaging

• Use as a first line tool in screening may not be appropriate due to

concerns of cost-effectiveness, accessibility, and radiation exposure

• Echocardiograms
• PRO: No direct adverse effects
• PRO: Useful for detecting cardiomyopathies, coronary anomalies
• CON: Time, accessibility
• CON: Does not detect coronary artery disease
• Stress echo does
• CT Angiography and Coronary Artery Calcium Scoring
• PRO: High sensitivity for detecting mild to moderate disease
• Will the results alter treatment decision making (i.e. take a statin)?
• Does it reduce morbidity and mortality?
• CON: Radiation exposure, cost
• Cardiac Magnetic Resonance Imaging (CMR)
• Limited availability, high cost, and low pre-test probability

Exercise Treadmill Test

CONS

• Does not (always) detect mild-

moderate plaque that is vulnerable to plaque rupture

• Poor sensitivity in population

with low pre-test probability (i.e. active individuals)

• False - positives à over

treatment PROS

• Predictive value of coronary artery

disease é as risk factors é

• Prognostic tool in risk stratifying

based on:

• Blood pressure response
• Complex ventricular ectopy
• Exercise capacity
• Heart rate profile (failure to reach

target heart rate, slow heart rate recovery)

Preliminary Results: Pre-Participation Screening and Cardiovascular Risk Assessment in Masters Athletes

What's Up Doc?

• Participant Dave
• 60 year old male
• Received highest health category on his life insurance

medical including ECG and blood work

• No family Hx of CAD, never smoked
• Physically fit, walks the dog and does the P90x workout

daily

• Just got back from the Olympics
• Just finished walking his dog in the forest on Bowen

Island, had chest painà St. Paul's à 100% LAD blockage à 3 stents in 4 hrs

800+ Masters Athletes

Negative Positive Exercise Treadmill Test and/or cardiologist consult Normal No Further Testing Abnormal Further Testing (echo, CACS, CTA, MIBI) Initial Screen (UBC Hospital, Fortius, other allied health centres) Framingham Risk Score, History and Personal Symptoms Questionnaire, Physical Exam, Resting ECG, Physical Activity, Lifestyle and Psychosocial Stress Questionnaire No significant CVD No Further Testing Cardiovascular Disease à Clinical Care

Everyone à Annual Follow-Up for 5 Years

Criteria for Exercise Treadmill Test (summary)

• Personal Symptoms
• Positive Family History
• Abnormal Physical Examination
• Abnormal resting ECG (ECG Specific Criteria: “Seattle

Criteria”)

• If FRS ≥ 10 and/or has a markedly raised single

cardiovascular risk factor

• Age ≥ 65

Criteria for Cardiology Consult and/or Further Testing (i.e. echo, CCT, holter)

• If stress test is positive or inconclusive
• An abnormal physical exam
• Family history of congenital heart
• ECG suggestive of cardiomyopathy
• FRS > 20

890$Masters$Athletes$$

!AHA$personal$and$family$history$ques6onnaire,$physical$ac6vity$and$lifestyle$ques6onnaire,$ FRS,$res6ng$12!lead$ECG,$physical$examina6on$

Excluded,$n=6$

! Did$not$meet$physical$ac6vity$criteria$$

Eligible$ n=884$ Kelowna$cohort$ n=98$ Vancouver$cohort$ n=650$ Victoria$cohort$ n=136$ Pending$$ follow!up$ n=90$ Normal$ n=39$ Normal$ n=46$ Pending$$ follow!up$ n=59$

Pending$ follow!up$ n=356$ Included$in$ analysis$ n=294$

Methods - Study Design

Population Characteristics

Number or athletes, n (%) 286 Male 191 (66.8) Female 95 (33.2) Age (years ±SD) 54.0 (8.8) Height (cm, ±SD) 173.7 (9.0) Weight (kg, ±SD) 75.0 (14.1) Body mass index (±SD) 24.6 (3.6) Waist circumference (cm, ±SD) 86.9 (9.8) Resting heart rate (bpm, ±SD) 58.0 (9.8) Systolic blood pressure (mm Hg, ±SD) 125.4 (15.1) Diastolic blood pressure (mm Hg, ±SD) 77.1 (8.0) Self-reported ethnicity, n (%) Caucasian 238 (83.2) Asian 18 (6.2) Other 20 (6.9) Not reported 10 (3.5)

5 10 15 20 25 30 35 40 45 All running Marathon Ultramarathon Running Hockey Cycling Triathlon Track and field (running) Other Mountain bike Paddling Alpine Skiing Soccer Cross-country skiing Tennis Golf Rowing Baseball Swimming Basketball Track and field (throwing) Lacrosse Rugby Field Hockey

Prevalence (%) of Sports Most Participated (Primary)

Further Evaluations and Diagnoses

Vancouver*Cohort*.*297*Masters*Athletes*

!AHA$personal$and$family$history$ques6onnaire,$physical$ac6vity$and$lifestyle$ques6onnaire,$FRS,$res6ng$12!lead$ECG,$physical$exam$

Normal$Screen$ No$Further$Tes6ng$ n$=$119$(41.7%)$ $ Abnormal$Screen$ n=167$(58.3%)$

$

Exercise$Treadmill$Test$and/or$cardiologist$ consult$ Normal$ No$Further$Tes6ng$ n=82$$ Abnormal$ Further$Tes6ng$ n=85$

$ $

Coronary$artery$anomaly$n=1$$ Probable$HCM$n=1$ BAV$n=1$ CAD$n=24$ Significant$valve$disease$n=4$ AF$n$=2$ Mul6ple$CVD$diagnoses$n=2$ $

Total*significant*CVD=35*(12.2%)* *

*

Excluded,$n=11$$

! Previous$CAD$(8)$ ! Did$not$meet$physical$ac6vity$criteria$(3)$

286$Masters$Athletes$Included$ No$significant$ CVD$ N=44$$

Wai6ng$further$ tests$n=3$ Declined$further$ tes6ng$n=3$

Age Sex Diagnoses, n=35 Abnormal Finding on Screen 74 63 59 48 58 68 59 65 65 64 M M M M M F M M M M MILD CAD (10) Single vessel Single vessel, calcified Single vessel, multifocal Minimal CCB Minimal CCB Single vessel, calcified Single vessel, calcified Single vessel, calcified Single vessel, mixed Double vessel, non-calcified FRS-H, > 65y, AFprev FRS-H FRS-I FRS-H Sx (SYN), ECG Sx (SOB), > 65y SVTprev ECG, FRS-H, > 65y Sx (SYN), ECG, FRS-H FRS-I 59 61 77 64 59 68 59 63 67 69 M M M M M M M M M M Moderate CAD (10) Mild-mod CAD - double vessel, mixed Mild-mod CAD – double vessel, calcified Mild-mod CAD - triple vessel Mild-mod CAD - double vessel, minimally calcified Mild-mod CAD – double vessel, mixed Mild to mod CAD – double vessel, mixed Mod CCB - double vessel Single vessel, mild diastolic dysfunction, high PVC burden (7178 PVCs) Mod CCB Triple vessel, mixed, mild AR Sx, ECG (ST), FRS-I FRS-I FRS-H, > 65y FRS-I FH, FRS-H FRS-I, > 65y, AFprev FRS-H FRS-I Sx, FRS-H, > 65y, Afprev ECG (LAD), FRS-I, > 65y 61 71 68 55 M F M M Significant CAD (4) Triple vessel Extensive CCB Single vessel, non-calcified Mild-significant CAD – triple vessel, mild-mod systolic dysfunction, mild MR, mild AR, mild AI FRS-H FRS-I, > 65y PE, FRS-H, > 65y PE, FRS-I

• No symptoms!
• all had risk factors
• 3 symptoms
• 2 abnormal ECGs
• 6 had risk factors

(4 were only indicator)

• 2 symptoms
• 2 abnormal ECGs
• all had risk factors

Age Sex Diagnoses, n=35 Abnormal Finding on Screen 56 70 M M Multiple CVD (2) CAD, valve disease, AF: Mild CAD - double vessel, calcified; Mild MVP, mild MR, mild AR, AF CAD, valve disease: Mild-mod CAD – triple vessel, mixed; AR, mod AI, diastolic dysfunction Sx, ECG (Q), FRS-I PE, FRS-H, > 65y 41 62 58 56 M M M M Inherited Heart Disease (4) Probable HCM Coronary artery anomaly (low risk) Bicuspid aortic valve Mild MVP, mild-mod MR, mild-mod AR ECG ECG, FRS-I FH, PE, ECG, FRS-H FH 57 63 59 M M M Valve Disease (3) Mild-mod MR; mild diastolic dysfunction Mild MR, mild diastolic dysfunction Mild AR, Mild AI FRS-I FH, FRS-I, AFprev PE, FRS-I 57 61 M M Atrial Fibrillation (2) Paroxysmal AF Persistent AF, mild-mod MR Sx (PAL), FH, ECG (LAD), FRS-H Sx (PAL), ECG (AF), FRS-I, SSSprev

Inherited heart disease

• 3/4 abnormal ECG
• 2 family history

AF

• All had symptoms
• All had abnormal ECG

Valve disease

• Physical exam

detected 3/7 (42.0%) cases

Positive Predictive Value of Screening Tools

Screening Tool Follow ups Indicated Positive Cases PPV (%) False- positive %

• Q. Personal symptoms
• Q. Family history
• Q. Previous CVD (excl CAD)

Total Questionnaire FRS-Intermediate 12-lead resting ECG Physical examination > 65 years old FRS-High 54 33 16 103 80 39 18 31 25 8 5 6 19 16 12 6 12 14 14.8 15.1 37.5 18.4 20.0 28.2 33.3 38.7 56.0 85.0 85.0 62.5 81.6 80.0 71.8 66.7 61.3 44.0

Cardiovascular Disease and Association with Weekly Volume of Physical Activity

15.1 11.7 3.2 0.9 1.6 0.9 0.8 0.9 0.8 2.2 0.9 1.6 17.4 15 8 13.0 10.5 5.6 2 4 6 8 10 12 14 16 18 20

15-40 41-75 > 75 Prevalence (%) MET-Hr/WK Total CAD Sig Valve Multiple CVD AF CHD Total CVD High FRS

• Greater volumes of activity had a

lower cardiovascular risk profile and lower prevalence of CVD

5 10 15 20 15-40 41-75 > 75 Prevalence of CVD (%) MET-Hr/Wk

Those That Exercised More Had a Lower Prevalence of CVD!

However….those who exercise more are not immune to cardiovascular disease

Masters Study Conclusions

• The majority of Masters athletes with significant CAD are

asymptomatic

• Masters athletes are not immune to cardiovascular risk factors
• Framingham Risk >20% exhibited the greatest PPV for

predicting disease (56.0%)

• PPS may be worthwhile in Masters athletes, however current

methods need to be refined

Participant Dave

• Would our screening tools detect?
• FH - no
• ECG - normal
• Physical exam - no?
• FRS > 10? à Yes? à ETT
• He did not have an exercise treadmill test
• 100% blockage
• Current study: 22/24 individuals with CAD
• 5-year longitudinal study…hope to determine best

screening tool

Conclusion: other factors to consider

No matter how perfect your screening methods are, it is impossible to detect everyone at risk for SCD

• 1. Ensuring emergency procedures are in place
• 2. Placement of AEDs in all sporting venues
• 3. Educate athletes on safe exercise participation and
• ther preventative strategies (i.e. monitor blood

pressure and lipids, maintain healthy body weight, proper diet)

• 4. Modified exercise for high-risk individuals
• 5. Promptly report and evaluate new and unusual

symptoms

Sanchis-Gomar et al., International Journal of Cardiology, Volume 197, 2015, 248–253

Recommendations: Summary

The absolute risk of SCD death is very low (0.75/100,0000 marathoners) Poorly trained males represent the high-risk group

Running 1- 3x/week at moderate pace has the greatest health benefits

Atrial Fibrillation Long-term competitive endurance activity increases the risk of AF (mainly lone AF) The actual long-term consequences and medical manageability remain to be determined Potential long-term remodeling? Some evidence of fibrosis in some highly trained athletes but veteran runners usually show youthful levels of heart function Pre-Participation Screening ü For all participants: physical examination, CVD history, ECG ü For old athletes (>65 years) and high-risk middle age adults exercise ECG Patients with known cardiovascular disease ü Supervised training with gradually increasing workloads

?

Exercise is vital in preventing CVD, risk factors, and 25 chronic diseases!!! (Warburton et al. CMAJ.2006)

Warm-Up

7 - 10+ minutes of light activity (walk or jog) + dynamic exercise (optional)

EXERCISE RECOMMENDATIONS: Gradual Progression

#1 - FREQUENCY Gradually Increase the frequency of your workouts to 3days/wk (low - moderate intensity)

#2 - INTENSITY Gradually increase INTENSITY and progress to 5 days/wk

Cool-Down and Recovery

ü 5-10 minutes ü Adequate recovery (longer duration and high intensity events warrant longer recovery) ü Protein, electrolytes (i.e. magnesium, sodium) replenishment for longer duration activities

Thank you!!

Questions??

www.SportsCardiologyBC.org